Discomfort Survey
FILL FORM
Discomfort survey
Date
*
Name
Job Title
*
Site
*
Spring Valley Centre
Hilton
Discovery Harbour
Sunridge Place
Normanna
Dania
Finnish Manor
Cartier House
Eden Care Centre
Andover Terrace
West Shore Laylum
Lynn Valley Care Centre
Dept
*
Shift
*
Height
*
Dominant Hand
*
Left
Right
Either
Gender
*
Male
Female
How long have you worked in your current position?
*
Less than 3 Months
3 Months to 1 Year
1 Year to 5 Years
5 Years to 10 Years
10+ Years
How often are you mentally exhausted after work?
*
Never
Occasionally
Often
Always
How often are you physically exhausted after work?
*
Never
Occasionally
Often
Always
Have you ever had any pain or discomfort during the last year that you believe is related to your work?
*
Yes
No
Neck
right
left
How Often (Neck)
*
Never
Occasionally
Often
Always
How Much (Neck)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Neck)
*
Yes
No
Possible Cause of Problem (Neck)
*
What Aggravates the Problem (Neck)
*
Shoulders
right
left
How Often (Shoulders)
*
Never
Option 2
Often
Always
How Much (Shoulders)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Shoulders)
*
Yes
No
Possible Cause of Problem (Shoulders)
*
What Aggravates the Problem (Shoulders)
*
Elbows
right
left
How Often (Elbows)
*
Never
Occasionally
Often
Always
How Much (Elbows)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Elbows)
*
Yes
No
Possible Cause of Problem (Elbows)
*
What Aggravates the Problem (Elbows)
*
Upper Back
right
left
How Often (Upper Back)
*
Never
Occasionally
Often
Always
How Much (Upper Back)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Upper Back)
*
Yes
No
Possible Cause of Problem (Upper Back)
*
What Aggravates the Problem (Upper Back)
*
Forearms
right
left
How Often (Forearms)
*
Never
Occasionally
Often
Always
How Much (Forearms)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Forearms)
*
Yes
No
Possible Cause of Problem (Forearms)
*
What Aggravates the Problem (Forearms)
*
Lower Back
right
left
How Often (Lower Back)
*
Never
Occasionally
Often
Always
How Much (Lower Back)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Lower Back)
*
Yes
No
Possible Cause of Problem (Lower Back)
*
What Aggravates the Problem (Lower Back)
*
Wrist/Hands
right
left
How Often (Wrist/Hands)
*
Never
Occasionally
Often
Always
How Much (Wrist/Hands)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Wrist/Hands)
*
Yes
No
Possible Cause of Problem (Wrist/Hands)
*
What Aggravates the Problem (Wrist/Hands)
*
Hips
right
left
How Often (Hips)
*
Never
Occasionally
Often
Always
How Much (Hips)
*
1
2
3
4
5
6
7
8
9
10
Previous Injury (Hips)
*
Yes
No
Possible Cause of Problem (Hips)
*
What Aggravates the Problem (Hips)
*
Thighs
right
left
How Often (Thighs)
*
Never
Occasionally
Often
Always
How Much (Thighs)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Thighs)
*
Yes
No
Possible Cause of Problem (Thighs)
*
What Aggravates the Problem (Thighs)
*
Knees
right
left
How Often (Knees)
*
Never
Occasionally
Often
Always
How Much (Knees)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Knees)
*
Yes
No
Possible Cause of Problem (Knees)
*
What Aggravates the Problem (Knees)
*
Ankles/Feet
right
left
How Often (Ankles/Feet)
*
Never
Occasionally
Often
Always
How Much (Ankles/Feet)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Ankles/Feet)
*
Yes
No
Possible Cause of Problem (Ankles/Feet)
*
What Aggravates the Problem (Ankles/Feet)
*
Lower Legs
right
left
How Often (Lower Legs)
*
Never
Occasionally
Often
Always
How Much (Lower Legs)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Lower Legs)
*
Yes
No
Possible Cause of Problem (Lower Legs)
*
What Aggravates the Problem (Lower Legs)
*
Other
How Often (Other)
*
Never
Occasionally
Often
Always
How Much (Other)
*
0
1
2
3
4
5
6
7
8
9
10
Previous Injury (Other)
*
Yes
No
Possible Cause of Problem (Other)
*
What Aggravates the Problem (Other)
*
Do you have any suggestions to improve your job tasks or additional comments?
Does your present job make your discomfort or pain worse?
Yes
No
Explain
Have you recieved any treatment (e.g. medication, hot/cold treatment, physiotherapy, etc.) to relieve the discomfort or pain?
Yes
No
Explain
Do you have any ideas what are the factors in your job (e.g. the object handled, the workstation, the work technique, tool used, etc.) causing the discomfort or pain?
Do you have any suggestions to improve the work condition to prevent or reduce the possibility of causing the discomfort or pain?
Date
Additional Notes (optional)
Email
